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Yu S, Ren J, Lv Z, Li R, Zhong Y, Yao W, Yuan J. Prediction of the endocrine-disrupting ability of 49 per- and polyfluoroalkyl substances: In silico and epidemiological evidence. CHEMOSPHERE 2022; 290:133366. [PMID: 34933031 DOI: 10.1016/j.chemosphere.2021.133366] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 06/14/2023]
Abstract
The toxic effects of per- and polyfluoroalkyl substances (PFASs) on humans are mediated by nuclear hormone receptors (NHRs). However, data on the interaction of PFASs and NHRs is limited. Endocrine Disruptome, an inverse docking tool, was used in this study to simulate the docking of 49 common PFASs with 14 different types of human NHRs. According to the findings, 25 PFASs have a high or moderately high probability of binding to more than five NHRs, with androgen receptor (AR) and mineralocorticoid receptor (MR) being the most likely target NHRs. Molecular docking analyses revealed that the binding modes of PFASs with the two NHRs were similar to those of their corresponding co-crystallized ligands. PFASs, in particular, may disrupt the endocrine system by binding to MR. This finding is consistent with epidemiological research that has linked PFASs to MR-related diseases. Our findings may contribute to a better understanding of the health risks posed by PFASs.
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Affiliation(s)
- Shuling Yu
- Key Laboratory of Natural Medicine and Immune-Engineering of Henan Province, Henan University, Kaifeng, Henan, 475004, PR China
| | - Jing Ren
- College of Public Health, Zhengzhou University, Zhengzhou, 450001, PR China
| | - Zhenxia Lv
- College of Public Health, Zhengzhou University, Zhengzhou, 450001, PR China
| | - Rui Li
- College of Public Health, Zhengzhou University, Zhengzhou, 450001, PR China
| | - Yuyan Zhong
- College of Public Health, Zhengzhou University, Zhengzhou, 450001, PR China
| | - Wu Yao
- College of Public Health, Zhengzhou University, Zhengzhou, 450001, PR China
| | - Jintao Yuan
- College of Public Health, Zhengzhou University, Zhengzhou, 450001, PR China.
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2
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Grossmann C, Almeida-Prieto B, Nolze A, Alvarez de la Rosa D. Structural and molecular determinants of mineralocorticoid receptor signalling. Br J Pharmacol 2021; 179:3103-3118. [PMID: 34811739 DOI: 10.1111/bph.15746] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/19/2021] [Accepted: 11/08/2021] [Indexed: 12/18/2022] Open
Abstract
During the past decades, the mineralocorticoid receptor (MR) has evolved from a much-overlooked member of the steroid hormone receptor family to an important player, not only in volume and electrolyte homeostasis but also in pathological changes occurring in an increasing number of tissues, especially the renal and cardiovascular systems. Simultaneously, a wealth of information about the structure, interaction partners and chromatin requirements for genomic signalling of steroid hormone receptors became available. However, much of the information for the MR has been deduced from studies of other family members and there is still a lack of knowledge about MR-specific features in ligand binding, chromatin remodelling, co-factor interactions and general MR specificity-conferring mechanisms that can completely explain the differences in pathophysiological function between MR and its closest relative, the glucocorticoid receptor. This review aims to give an overview of the current knowledge of MR structure, signalling and co-factors modulating its activity.
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Affiliation(s)
- Claudia Grossmann
- Julius Bernstein Institute of Physiology, Martin Luther University Halle-Wittenberg, Halle, Saale, Germany
| | - Brian Almeida-Prieto
- Departamento de Ciencias Médicas Básicas and Instituto de Tecnologías Biomédicas, Universidad de La Laguna, La Laguna, Tenerife, Spain
| | - Alexander Nolze
- Julius Bernstein Institute of Physiology, Martin Luther University Halle-Wittenberg, Halle, Saale, Germany
| | - Diego Alvarez de la Rosa
- Departamento de Ciencias Médicas Básicas and Instituto de Tecnologías Biomédicas, Universidad de La Laguna, La Laguna, Tenerife, Spain
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3
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Gadasheva Y, Nolze A, Grossmann C. Posttranslational Modifications of the Mineralocorticoid Receptor and Cardiovascular Aging. Front Mol Biosci 2021; 8:667990. [PMID: 34124152 PMCID: PMC8193679 DOI: 10.3389/fmolb.2021.667990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/07/2021] [Indexed: 01/05/2023] Open
Abstract
During aging, the cardiovascular system is especially prone to a decline in function and to life-expectancy limiting diseases. Cardiovascular aging is associated with increased arterial stiffness and vasoconstriction as well as left ventricular hypertrophy and reduced diastolic function. Pathological changes include endothelial dysfunction, atherosclerosis, fibrosis, hypertrophy, inflammation, and changes in micromilieu with increased production of reactive oxygen and nitrogen species. The renin-angiotensin-aldosterone-system is an important mediator of electrolyte and blood pressure homeostasis and a key contributor to pathological remodeling processes of the cardiovascular system. Its effects are partially conveyed by the mineralocorticoid receptor (MR), a ligand-dependent transcription factor, whose activity increases during aging and cardiovascular diseases without correlating changes of its ligand aldosterone. There is growing evidence that the MR can be enzymatically and non-enzymatically modified and that these modifications contribute to ligand-independent modulation of MR activity. Modifications reported so far include phosphorylation, acetylation, ubiquitination, sumoylation and changes induced by nitrosative and oxidative stress. This review focuses on the different posttranslational modifications of the MR, their impact on MR function and degradation and the possible implications for cardiovascular aging and diseases.
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Affiliation(s)
- Yekatarina Gadasheva
- Julius-Bernstein-Institute of Physiology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Alexander Nolze
- Julius-Bernstein-Institute of Physiology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Claudia Grossmann
- Julius-Bernstein-Institute of Physiology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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4
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Hanukoglu A, Vargas-Poussou R, Landau Z, Yosovich K, Hureaux M, Zennaro MC. Renin-aldosterone system evaluation over four decades in an extended family with autosomal dominant pseudohypoaldosteronism due to a deletion in the NR3C2 gene. J Steroid Biochem Mol Biol 2020; 204:105755. [PMID: 33017655 DOI: 10.1016/j.jsbmb.2020.105755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Abstract
Renal pseudohypoaldosteronism (PHA1) is a mild form of an aldosterone-resistance syndrome caused by mutations in the NR3C2 gene that codes for the mineralocorticoid receptor (MR). The disease is inherited as an autosomal dominant trait characterized by signs and symptoms of salt-losing in infancy. Disease manifestations could be severe in infancy but improve after the age of 1-3 years. Some affected members are asymptomatic and remain so life-long. In this study, we report the identification of a large deletion in the NR3C2 gene (c.1897+1_1898-1)_(c.*2955+?)del in renal PHA1 patients from an extended family spanning four generations. We prospectively evaluated the plasma renin activity and serum aldosterone profiles over four decades in symptomatic and asymptomatic affected family members. The benefits of early diagnosis on the clinical outcome were assessed as well. The long-term follow-up showed an age-dependent decrease in both plasma renin activity and serum aldosterone levels over the years. However, aldosterone levels remain high life-long. Thus, levels of aldosterone are a reliable marker to detect asymptomatic family members. The diagnosis of the proposita led to early diagnosis and therapy in other affected family members, significantly mitigating the clinical course. Despite the extremely elevated serum aldosterone levels during pregnancy, affected pregnant women did not experience any ill effects. However, this should be verified by observations in other adult patients.
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Affiliation(s)
- Aaron Hanukoglu
- Division of Pediatric Endocrinology, E. Wolfson Medical Center, Holon, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Rosa Vargas-Poussou
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France; Centre de Références de Maladies Rénales Rares de l'Enfant et d'Adulte (MARHEA)
| | - Zohar Landau
- Division of Pediatric Endocrinology, E. Wolfson Medical Center, Holon, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Keren Yosovich
- Molecular Genetics Lab, Wolfson Medical Center, Holon, Israel
| | - Marguerite Hureaux
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France; Inserm, PARCC, Université de Paris, F-75015 Paris, France
| | - Maria-Christina Zennaro
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France; Inserm, PARCC, Université de Paris, F-75015 Paris, France
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5
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Mihailidou AS, Tzakos AG, Ashton AW. Non-Genomic Effects of Aldosterone. VITAMINS AND HORMONES 2019; 109:133-149. [DOI: 10.1016/bs.vh.2018.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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6
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Zennaro MC, Fernandes-Rosa F. 30 YEARS OF THE MINERALOCORTICOID RECEPTOR: Mineralocorticoid receptor mutations. J Endocrinol 2017; 234:T93-T106. [PMID: 28348114 DOI: 10.1530/joe-17-0089] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 03/27/2017] [Indexed: 12/12/2022]
Abstract
Aldosterone and the mineralocorticoid receptor (MR) are key elements for maintaining fluid and electrolyte homeostasis as well as regulation of blood pressure. Loss-of-function mutations of the MR are responsible for renal pseudohypoaldosteronism type 1 (PHA1), a rare disease of mineralocorticoid resistance presenting in the newborn with weight loss, failure to thrive, vomiting and dehydration, associated with hyperkalemia and metabolic acidosis, despite extremely elevated levels of plasma renin and aldosterone. In contrast, a MR gain-of-function mutation has been associated with a familial form of inherited mineralocorticoid hypertension exacerbated by pregnancy. In addition to rare variants, frequent functional single nucleotide polymorphisms of the MR are associated with salt sensitivity, blood pressure, stress response and depression in the general population. This review will summarize our knowledge on MR mutations in PHA1, reporting our experience on the genetic diagnosis in a large number of patients performed in the last 10 years at a national reference center for the disease. We will also discuss the influence of rare MR variants on blood pressure and salt sensitivity as well as on stress and cognitive functions in the general population.
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Affiliation(s)
- Maria-Christina Zennaro
- INSERMParis Cardiovascular Research Center, Paris, France
- Université Paris DescartesSorbonne Paris Cité, Paris, France
- Assistance Publique-Hôpitaux de ParisHôpital Européen Georges Pompidou, Service de Génétique, Paris, France
| | - Fabio Fernandes-Rosa
- INSERMParis Cardiovascular Research Center, Paris, France
- Université Paris DescartesSorbonne Paris Cité, Paris, France
- Assistance Publique-Hôpitaux de ParisHôpital Européen Georges Pompidou, Service de Génétique, Paris, France
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7
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Vitellius G, Fagart J, Delemer B, Amazit L, Ramos N, Bouligand J, Le Billan F, Castinetti F, Guiochon-Mantel A, Trabado S, Lombès M. Three Novel Heterozygous Point Mutations ofNR3C1Causing Glucocorticoid Resistance. Hum Mutat 2016; 37:794-803. [DOI: 10.1002/humu.23008] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 04/12/2016] [Indexed: 12/28/2022]
Affiliation(s)
- Géraldine Vitellius
- INSERM UMR S 1185, Fac Med Paris Sud, Univ. Paris Sud; Université Paris-Saclay; Le Kremlin Bicêtre F-94276 France
| | - Jérôme Fagart
- INSERM UMR S 1185, Fac Med Paris Sud, Univ. Paris Sud; Université Paris-Saclay; Le Kremlin Bicêtre F-94276 France
| | - Brigitte Delemer
- Service d'Endocrinologie; Hôpital Robert Debré; CHU Reims; Reims F-51100 France
| | - Larbi Amazit
- INSERM UMR S 1185, Fac Med Paris Sud, Univ. Paris Sud; Université Paris-Saclay; Le Kremlin Bicêtre F-94276 France
- INSERM UMS-32, Institut Biomédical de Bicêtre; Univ. Paris Sud; Université Paris-Saclay; Le Kremlin Bicêtre F-94275 France
| | - Nelly Ramos
- INSERM UMR S 1185, Fac Med Paris Sud, Univ. Paris Sud; Université Paris-Saclay; Le Kremlin Bicêtre F-94276 France
| | - Jérôme Bouligand
- INSERM UMR S 1185, Fac Med Paris Sud, Univ. Paris Sud; Université Paris-Saclay; Le Kremlin Bicêtre F-94276 France
- Service de Génétique Moléculaire; Pharmacogénétique et Hormonologie; Hôpitaux Universitaires Paris Sud; CHU Bicêtre F-94275 France
| | - Florian Le Billan
- INSERM UMR S 1185, Fac Med Paris Sud, Univ. Paris Sud; Université Paris-Saclay; Le Kremlin Bicêtre F-94276 France
| | - Frédéric Castinetti
- Service d'Endocrinologie; Hôpital de la Timone; CHU Marseille; Marseille F-13385 France
| | - Anne Guiochon-Mantel
- INSERM UMR S 1185, Fac Med Paris Sud, Univ. Paris Sud; Université Paris-Saclay; Le Kremlin Bicêtre F-94276 France
- Service de Génétique Moléculaire; Pharmacogénétique et Hormonologie; Hôpitaux Universitaires Paris Sud; CHU Bicêtre F-94275 France
| | - Séverine Trabado
- INSERM UMR S 1185, Fac Med Paris Sud, Univ. Paris Sud; Université Paris-Saclay; Le Kremlin Bicêtre F-94276 France
- Service de Génétique Moléculaire; Pharmacogénétique et Hormonologie; Hôpitaux Universitaires Paris Sud; CHU Bicêtre F-94275 France
| | - Marc Lombès
- INSERM UMR S 1185, Fac Med Paris Sud, Univ. Paris Sud; Université Paris-Saclay; Le Kremlin Bicêtre F-94276 France
- Service d'Endocrinologie et des Maladies de la Reproduction; Hôpitaux Universitaires Paris Sud; CHU Bicêtre; Le Kremlin Bicêtre F-94275 France
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8
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Patel SR, Skafar DF. Modulation of nuclear receptor activity by the F domain. Mol Cell Endocrinol 2015; 418 Pt 3:298-305. [PMID: 26184856 DOI: 10.1016/j.mce.2015.07.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/09/2015] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
Abstract
The F domain located at the C-terminus of proteins is one of the least conserved regions of the estrogen receptors alpha and beta, members of the nuclear hormone receptor superfamily. Indeed, many members of the superfamily lack the F domain. However, when present, removing the F domain entirely or mutating it alters transactivation, dimerization, and the responses to agonist and antagonist ligands. This review focuses on the functions of the F domain of the estrogen receptors, particularly in relation to other members of the superfamily.
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Affiliation(s)
- Shivali R Patel
- Department of Physiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Debra F Skafar
- Department of Physiology, Wayne State University School of Medicine, Detroit, MI, USA.
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9
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Gleason CE, Frindt G, Cheng CJ, Ng M, Kidwai A, Rashmi P, Lang F, Baum M, Palmer LG, Pearce D. mTORC2 regulates renal tubule sodium uptake by promoting ENaC activity. J Clin Invest 2014; 125:117-28. [PMID: 25415435 DOI: 10.1172/jci73935] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 10/23/2014] [Indexed: 12/17/2022] Open
Abstract
The epithelial Na+ channel (ENaC) is essential for Na+ homeostasis, and dysregulation of this channel underlies many forms of hypertension. Recent studies suggest that mTOR regulates phosphorylation and activation of serum/glucocorticoid regulated kinase 1 (SGK1), which is known to inhibit ENaC internalization and degradation; however, it is not clear whether mTOR contributes to the regulation of renal tubule ion transport. Here, we evaluated the effect of selective mTOR inhibitors on kidney tubule Na+ and K+ transport in WT and Sgk1-/- mice, as well as in isolated collecting tubules. We found that 2 structurally distinct competitive inhibitors (PP242 and AZD8055), both of which prevent all mTOR-dependent phosphorylation, including that of SGK1, caused substantial natriuresis, but not kaliuresis, in WT mice, which indicates that mTOR preferentially influences ENaC function. PP242 also substantially inhibited Na+ currents in isolated perfused cortical collecting tubules. Accordingly, patch clamp studies on cortical tubule apical membranes revealed that mTOR inhibition markedly reduces ENaC activity, but does not alter activity of K+ inwardly rectifying channels (ROMK channels). Together, these results demonstrate that mTOR regulates kidney tubule ion handling and suggest that mTOR regulates Na+ homeostasis through SGK1-dependent modulation of ENaC activity.
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10
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Hudson WH, Youn C, Ortlund EA. Crystal structure of the mineralocorticoid receptor DNA binding domain in complex with DNA. PLoS One 2014; 9:e107000. [PMID: 25188500 PMCID: PMC4154765 DOI: 10.1371/journal.pone.0107000] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 08/12/2014] [Indexed: 01/21/2023] Open
Abstract
The steroid hormone receptors regulate important physiological functions such as reproduction, metabolism, immunity, and electrolyte balance. Mutations within steroid receptors result in endocrine disorders and can often drive cancer formation and progression. Despite the conserved three-dimensional structure shared among members of the steroid receptor family and their overlapping DNA binding preference, activation of individual steroid receptors drive unique effects on gene expression. Here, we present the first structure of the human mineralocorticoid receptor DNA binding domain, in complex with a canonical DNA response element. The overall structure is similar to the glucocorticoid receptor DNA binding domain, but small changes in the mode of DNA binding and lever arm conformation may begin to explain the differential effects on gene regulation by the mineralocorticoid and glucocorticoid receptors. In addition, we explore the structural effects of mineralocorticoid receptor DNA binding domain mutations found in type I pseudohypoaldosteronism and multiple types of cancer.
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MESH Headings
- Amino Acid Sequence
- Crystallography, X-Ray
- DNA/chemistry
- DNA/genetics
- DNA/metabolism
- Escherichia coli/genetics
- Escherichia coli/metabolism
- Gene Expression
- Humans
- Molecular Sequence Data
- Mutation
- Neoplasms/genetics
- Neoplasms/metabolism
- Neoplasms/pathology
- Protein Structure, Secondary
- Protein Structure, Tertiary
- Pseudohypoaldosteronism/genetics
- Pseudohypoaldosteronism/metabolism
- Pseudohypoaldosteronism/pathology
- Receptors, Glucocorticoid/chemistry
- Receptors, Glucocorticoid/genetics
- Receptors, Glucocorticoid/metabolism
- Receptors, Mineralocorticoid/chemistry
- Receptors, Mineralocorticoid/genetics
- Receptors, Mineralocorticoid/metabolism
- Recombinant Proteins/chemistry
- Recombinant Proteins/genetics
- Recombinant Proteins/metabolism
- Sequence Alignment
- Structural Homology, Protein
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Affiliation(s)
- William H. Hudson
- Department of Biochemistry, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Discovery and Developmental Therapeutics, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Christine Youn
- Department of Biochemistry, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Discovery and Developmental Therapeutics, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Eric A. Ortlund
- Department of Biochemistry, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Discovery and Developmental Therapeutics, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, United States of America
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11
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Abstract
The primary adrenal cortical steroid hormones, aldosterone, and the glucocorticoids cortisol and corticosterone, act through the structurally similar mineralocorticoid (MR) and glucocorticoid receptors (GRs). Aldosterone is crucial for fluid, electrolyte, and hemodynamic homeostasis and tissue repair; the significantly more abundant glucocorticoids are indispensable for energy homeostasis, appropriate responses to stress, and limiting inflammation. Steroid receptors initiate gene transcription for proteins that effect their actions as well as rapid non-genomic effects through classical cell signaling pathways. GR and MR are expressed in many tissues types, often in the same cells, where they interact at molecular and functional levels, at times in synergy, others in opposition. Thus the appropriate balance of MR and GR activation is crucial for homeostasis. MR has the same binding affinity for aldosterone, cortisol, and corticosterone. Glucocorticoids activate MR in most tissues at basal levels and GR at stress levels. Inactivation of cortisol and corticosterone by 11β-HSD2 allows aldosterone to activate MR within aldosterone target cells and limits activation of the GR. Under most conditions, 11β-HSD1 acts as a reductase and activates cortisol/corticosterone, amplifying circulating levels. 11β-HSD1 and MR antagonists mitigate inappropriate activation of MR under conditions of oxidative stress that contributes to the pathophysiology of the cardiometabolic syndrome; however, MR antagonists decrease normal MR/GR functional interactions, a particular concern for neurons mediating cognition, memory, and affect.
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Affiliation(s)
- Elise Gomez-Sanchez
- G.V.(Sonny) Montgomery V.A. Medical Center and Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Celso E. Gomez-Sanchez
- G.V.(Sonny) Montgomery V.A. Medical Center and Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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12
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Piotrowski DW. Mineralocorticoid Receptor Antagonists for the Treatment of Hypertension and Diabetic Nephropathy. J Med Chem 2012; 55:7957-66. [DOI: 10.1021/jm300806c] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- David W. Piotrowski
- Pfizer Worldwide Medicinal Chemistry, Eastern Point Road, Groton,
Connecticut 06340, United States
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13
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Zennaro MC, Hubert EL, Fernandes-Rosa FL. Aldosterone resistance: structural and functional considerations and new perspectives. Mol Cell Endocrinol 2012; 350:206-15. [PMID: 21664233 DOI: 10.1016/j.mce.2011.04.023] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 04/20/2011] [Accepted: 04/24/2011] [Indexed: 11/30/2022]
Abstract
Aldosterone plays an essential role in the maintenance of fluid and electrolyte homeostasis in the distal nephron. Loss-of-function mutations in two key components of the aldosterone response, the mineralocorticoid receptor and the epithelial sodium channel ENaC, lead to type 1 pseudohypoaldosteronism (PHA1), a rare genetic disease of aldosterone resistance characterized by salt wasting, dehydration, failure to thrive, hyperkalemia and metabolic acidosis. This review describes the clinical, biological and genetic characteristics of the different forms of PHA1 and highlights recent advances in the understanding of the pathogenesis of the disease. We will also discuss genotype-phenotype correlations and new clinical and genetic entities that may prove relevant for patient's care in neonates with renal salt losing syndromes and/or failure to thrive.
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14
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Huyet J, Pinon GM, Fay MR, Rafestin-Oblin ME, Fagart J. Structural determinants of ligand binding to the mineralocorticoid receptor. Mol Cell Endocrinol 2012; 350:187-95. [PMID: 21820032 DOI: 10.1016/j.mce.2011.07.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 07/15/2011] [Accepted: 07/17/2011] [Indexed: 11/15/2022]
Abstract
The first and critical step in the mechanism of aldosterone action is its binding to the mineralocorticoid receptor (MR), a member of the nuclear receptor superfamily. Over the last 40 years, numerous studies have attempted to determine the structural determinants of ligand-binding to MR. An initial set of data showed that hsp90 is bound to the receptor via specific regions and maintains it in a ligand-binding competent state. Site-directed mutagenesis and functional studies guided by a 3D model of the MR ligand-binding domain (LBD) made it possible to identify the residues responsible for the high affinity and selectivity for aldosterone, and to characterize the mechanisms of MR activation and inactivation. The recent determination of the X-ray crystal structures of the LBD of the wild-type MR and MR(S810L), which is responsible for a familial form of hypertension, has made it possible to elucidate the peculiar mechanism of activation of MR(S810L) and established a clear structure/activity relationship for steroidal and non-steroidal MR antagonists.
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Affiliation(s)
- Jessica Huyet
- INSERM U773, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France
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15
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Fernandes-Rosa FL, Hubert EL, Fagart J, Tchitchek N, Gomes D, Jouanno E, Benecke A, Rafestin-Oblin ME, Jeunemaitre X, Antonini SR, Zennaro MC. Mineralocorticoid receptor mutations differentially affect individual gene expression profiles in pseudohypoaldosteronism type 1. J Clin Endocrinol Metab 2011; 96:E519-27. [PMID: 21159846 DOI: 10.1210/jc.2010-1486] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Type 1 pseudohypoaldosteronism (PHA1), a primary form of mineralocorticoid resistance, is due to inactivating mutations of the NR3C2 gene, coding for the mineralocorticoid receptor (MR). OBJECTIVE The objective of the study was to assess whether different NR3C2 mutations have distinct effects on the pattern of MR-dependent transcriptional regulation of aldosterone-regulated genes. DESIGN AND METHODS Four MR mutations affecting residues in the ligand binding domain, identified in families with PHA1, were tested. MR proteins generated by site-directed mutagenesis were analyzed for their binding to aldosterone and were transiently transfected into renal cells to explore the functional effects on the transcriptional activity of the receptors by cis-trans-cotransactivation assays and by measuring the induction of endogenous gene transcription. RESULTS Binding assays showed very low or absent aldosterone binding for mutants MR(877Pro), MR(848Pro), and MR(947stop) and decreased affinity for aldosterone of MR(843Pro). Compared with wild-type MR, the mutations p.Leu843Pro and p.Leu877Pro displayed half-maximal aldosterone-dependent transactivation of reporter genes driven by mouse mammary tumor virus or glucocorticoid response element-2 dependent promoters, whereas MR(848Pro) and MR(947stop) nearly or completely lost transcriptional activity. Although MR(848Pro) and MR(947stop) were also incapable of inducing aldosterone-dependent gene expression of endogenous sgk1, GILZ, NDRG2, and SCNN1A, MR(843Pro) retained complete transcriptional activity on sgk1 and GILZ gene expression, and MR(877Pro) negatively affected the expression of sgk1, NDRG2, and SCNN1A. CONCLUSIONS Our data demonstrate that MR mutations differentially affect individual gene expression in a promoter-dependent manner. Investigation of differential gene expression profiles in PHA1 may allow a better understanding of the molecular substrate of phenotypic variability and to elucidate pathogenic mechanisms underlying the disease.
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Affiliation(s)
- Fábio L Fernandes-Rosa
- Department of Puericulture and Pediatrics, School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto 14040-900, Brazil
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16
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Fagart J, Hillisch A, Huyet J, Bärfacker L, Fay M, Pleiss U, Pook E, Schäfer S, Rafestin-Oblin ME, Kolkhof P. A new mode of mineralocorticoid receptor antagonism by a potent and selective nonsteroidal molecule. J Biol Chem 2010; 285:29932-40. [PMID: 20650892 DOI: 10.1074/jbc.m110.131342] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Limitations of current steroidal mineralocorticoid receptor (MR) antagonists have stimulated the search for a new generation of molecules. We screened for novel nonsteroidal compounds and identified MR antagonists derived from the chemical class of dihydropyridines. Chemical optimization resulted in BR-4628, which displays high in vitro and in vivo MR potency as well as selectivity with respect to the other steroid hormone receptors and the L-type calcium channel. Biochemical studies demonstrated that BR-4628 forms complexes with MR that do not promote the recruitment of transcriptional co-regulators. Docking experiments, using the crystal structure of the MR ligand-binding domain in an agonist conformation, revealed that BR-4628 accommodates in the MR ligand-binding cavity differently in comparison with the classical steroidal MR antagonists. An alanine scanning mutagenesis approach, based on BR-4628 docking, allowed identifying its anchoring mode within the ligand-binding cavity. Altogether, we propose that BR-4628 is a bulky antagonist that inactivates MR through a passive mechanism. It represents the prototype of a new class of MR antagonists.
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Affiliation(s)
- Jérôme Fagart
- Department of Medicinal Chemistry, Bayer Schering Pharma AG, Global Drug Discovery, 42096 Wuppertal, Germany
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17
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Fernandes-Rosa FL, Antonini SRR. [Mineralocorticoid resistance: pseudohypoaldosteronism type 1]. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2007; 51:373-81. [PMID: 17546235 DOI: 10.1590/s0004-27302007000300004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Accepted: 10/22/2006] [Indexed: 05/15/2023]
Abstract
Pseudohypoaldosteronism type 1 (PHA1) is a rare genetic disease characterized by neonatal renal salt wasting, vomiting, dehydration and failure to thrive. Affected patients present hyponatremia, hyperkalemia, associated with high levels of plasma renin and aldosterone resulting from a renal or systemic resistance to aldosterone. The systemic form of PHA1 results in a severe phenotype, and high doses of salt supplementation are necessary. The symptoms are life-long recurrent. This form is associated with autosomal recessive transmission. Homozygous or compound heterozygous loss of function mutations in the genes coding for the epithelial sodium channel (ENaC) subunities are responsible for this disease. The renal form of PHA1 results in a mild phenotype. Low doses of salt supplementation are required and usually the symptoms remit at the end of the first year of life. Heterozygous loss-of-function mutations in the mineralocorticoid receptor (MR) gene are associated with the renal form of PHA1 in the majority of the affected families but sporadic cases have been reported. In this review the mechanisms of aldosterone action and its effects are discussed. Additionally, clinical and molecular findings of a Brazilian family with the renal form of PHA1 caused by a nonsense mutation (R947X) in the MR gene are presented.
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Affiliation(s)
- Fábio L Fernandes-Rosa
- Departamento de Puericultura e Pediatria, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, SP
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18
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Lu NZ, Wardell SE, Burnstein KL, Defranco D, Fuller PJ, Giguere V, Hochberg RB, McKay L, Renoir JM, Weigel NL, Wilson EM, McDonnell DP, Cidlowski JA. International Union of Pharmacology. LXV. The pharmacology and classification of the nuclear receptor superfamily: glucocorticoid, mineralocorticoid, progesterone, and androgen receptors. Pharmacol Rev 2007; 58:782-97. [PMID: 17132855 DOI: 10.1124/pr.58.4.9] [Citation(s) in RCA: 267] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
MESH Headings
- Animals
- Hormone Antagonists/adverse effects
- Hormone Antagonists/therapeutic use
- Humans
- Ligands
- Mutation
- Receptors, Androgen/genetics
- Receptors, Androgen/physiology
- Receptors, Cytoplasmic and Nuclear/classification
- Receptors, Cytoplasmic and Nuclear/genetics
- Receptors, Cytoplasmic and Nuclear/physiology
- Receptors, Glucocorticoid/genetics
- Receptors, Glucocorticoid/physiology
- Receptors, Mineralocorticoid/genetics
- Receptors, Mineralocorticoid/physiology
- Receptors, Progesterone/genetics
- Receptors, Progesterone/physiology
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Affiliation(s)
- Nick Z Lu
- Molecular Endocrinology Group, Laboratory of Signal Transduction, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina 27709, USA
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19
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Pujo L, Fagart J, Gary F, Papadimitriou DT, Claës A, Jeunemaître X, Zennaro MC. Mineralocorticoid receptor mutations are the principal cause of renal type 1 pseudohypoaldosteronism. Hum Mutat 2007; 28:33-40. [PMID: 16972228 DOI: 10.1002/humu.20371] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Aldosterone plays a key role in electrolyte balance and blood pressure regulation. Type 1 pseudohypoaldosteronism (PHA1) is a primary form of mineralocorticoid resistance characterized in the newborn by salt wasting, hyperkalemia, and failure to thrive. Inactivating mutations of the mineralocorticoid receptor (MR; NR3C2) are responsible for autosomal dominant and some sporadic cases of PHA1. The question as to whether other genes may be involved in the disease is of major importance because of the potential life-threatening character of the disease, the potential cardiovascular effects of compensatory aldosterone excess, and the role of the mineralocorticoid system in human hypertension. We present the first comprehensive study seeking nucleotide substitutions in coding regions, intron-exon junctions, and untranslated exons, as well as for large deletions. A total of 22 MR gene abnormalities were found in 33 patients. We demonstrate that MR mutations are extremely frequent in PHA1 patients classified according to aldosterone and potassium levels and give indications for accurate clinical and biological investigation. In our study the possibility of a genocopy exists in three PHA1 kindreds. The other patients without MR mutations might have different diseases resembling to PHA1 in the neonatal period, which could be identified by extensive clinical and functional exploration.
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Affiliation(s)
- Lucie Pujo
- Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Department of Genetics, Paris, France
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20
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Skøtt O, Uhrenholt TR, Schjerning J, Hansen PBL, Rasmussen LE, Jensen BL. Rapid actions of aldosterone in vascular health and disease—friend or foe? Pharmacol Ther 2006; 111:495-507. [PMID: 16413609 DOI: 10.1016/j.pharmthera.2005.10.010] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Accepted: 10/28/2005] [Indexed: 02/07/2023]
Abstract
The mineralocorticoid receptor (MR) and the enzyme 11betahydroxysteroid dehydrogenase type 2, which confers aldosterone specificity to the MR, are present in endothelium and vascular smooth muscle. In several pathological conditions aldosterone promotes vascular damage by formation of reactive oxygen species. The effect of aldosterone on vascular function, however, is far from clear. By rapid non-genomic mechanisms aldosterone may cause calcium mobilization and vasoconstriction, or may stimulate nitric oxide formation through the PI-3 kinase/Akt pathway and thereby counteract vasoconstriction. Vasoconstrictor, vasodilator or no effects of aldosterone have been reported from studies on human forearm blood flow. Inhibition of MR with spironolactone improves endothelial function in patients with heart failure but worsens endothelial function in type 2 diabetic patients. The aim of the present review is to reconcile some of the apparently conflicting data. A key observation is that reactive oxygen and nitrogen species serve as physiological signaling molecules at low concentrations, while they initiate pathological processes at higher concentrations. The net effect of aldosterone, which stimulates ROS production, therefore depends on the ambient level of oxidative stress. Thus, in situations with low levels of oxidative stress aldosterone may promote vasodilatation, while at higher oxidative stress (high NaCl intake, pre-existing vascular pathological conditions, high oxygen tension in vitro) aldosterone is likely to be associated with vasoconstriction and oxidative damage, and in this setting inhibition of the MR is likely to be beneficial.
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Affiliation(s)
- Ole Skøtt
- Department of Physiology and Pharmacology, University of Southern Denmark, DK-5000 Odense, Denmark.
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21
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McDonald SE, Henderson TA, Gomez-Sanchez CE, Critchley HOD, Mason JI. 11Beta-hydroxysteroid dehydrogenases in human endometrium. Mol Cell Endocrinol 2006; 248:72-8. [PMID: 16406280 DOI: 10.1016/j.mce.2005.12.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Key reproductive events, such as menstruation and implantation, are considered to be inflammatory processes and glucocorticoids act as anti-inflammatory agents. The balance of expression of types 1 and 2 11beta-hydroxysteroid dehydrogenases (11betaHSD) controls the availability of cortisol to bind to the glucocorticoid receptor (GR) and mineralocorticoid receptor (MR). Expression profiles of glucocorticoid-metabolising enzymes and their cognate receptors have been characterized in the reproductive tract. We propose that factors that peripherally promote glucocorticoid action are part of an anti-inflammatory response to tissue remodelling in human endometrium. Protein and mRNA expression in endometrium were investigated using immunohistochemistry and quantitative real-time PCR. There was up-regulated expression of 11betaHSD-1 at menstruation and in first trimester decidua. 11BetaHSD-2 and GR were expressed across the cycle. The MR expression pattern across the cycle and in decidua implies progesterone may also play a regulatory role. The precise roles and interactions of these proteins require further investigation.
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Affiliation(s)
- Sarah E McDonald
- Reproductive and Developmental Sciences, Centre for Reproductive Biology, University of Edinburgh School of Clinical Sciences and Community Health, Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
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22
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Elhaji YA, Stoica I, Dennis S, Purisima EO, Lumbroso R, Beitel LK, Trifiro MA. Impaired helix 12 dynamics due to proline 892 substitutions in the androgen receptor are associated with complete androgen insensitivity. Hum Mol Genet 2006; 15:921-31. [PMID: 16449235 DOI: 10.1093/hmg/ddl009] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Structural studies of the ligand-binding domain (LBD) of several steroid receptors have revealed that the dynamic properties of the C-terminal helix 12 (H12) are the major determinant of the activation mode of these receptors. H12 exhibits high mobility and different conformations in the absence of ligand. Upon ligand binding, H12 is stabilized in a precise position to seal the ligand-binding pocket and finalize the assembly of the activation function (AF-2) domain. In this study, we investigated the role of the conserved proline 892 of the androgen receptor (AR) in directing the dynamic location and orientation of the AR-H12. We used a combined approach including kinetic and biochemical assays with molecular dynamic simulations to analyze two substitutions (P892A and P892L) identified in individuals with complete androgen insensitivity syndrome. Our analyses revealed distinct mechanisms by which these substitutions impair H12 function resulting in severely defective receptors. The AR-P892A receptor exhibited reduced ligand binding and transactivational potential because of an increased flexibility in H12. The AR-P892L substitution renders the receptor inactive due to a distorted, unstructured and misplaced H12. To confirm the mutants' inability to stabilize H12 in an active position, we have developed a novel in vivo assay to evaluate the accessibility of the H12-docking site on the AR-LBD surface. An extrinsic AR-H12 peptide was able to interact with wild-type and mutant LBDs in the absence of ligand. Ligand-induced proper positioning of the intrinsic H12 of wild-type AR prevented these interactions, whereas the misplacement of the mutants' H12 did not. Proline at this position may be critical for H12 dynamics not only in the AR, but also in other nuclear receptors where this proline is conserved.
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Affiliation(s)
- Youssef A Elhaji
- Lady Davis Institute for Medical Research, Sir Mortimer B. Davis Jewish General Hospital, McGill University, National Research Council of Canada, Montreal, Que., Canada.
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23
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DeRijk R, de Kloet ER. Corticosteroid receptor genetic polymorphisms and stress responsivity. Endocrine 2005; 28:263-70. [PMID: 16388115 DOI: 10.1385/endo:28:3:263] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2005] [Accepted: 07/13/2005] [Indexed: 11/11/2022]
Abstract
A fundamental question in the neuroendocrinology of stress-related psychopathology is why some individuals flourish and others perish under similar adverse conditions. In this contribution we focus on the variants of mineralocorticorticoid (MR) and glucocorticoid receptors (GR) that operate in balance and coordinate behavioral, autonomic, and neuroendocrine response patterns involved in homeostasis and health. In the GR-gene, three single nucleotide polymorphism (SNPs) have been associated with changes in metabolic profile and cardiovascular parameters: the ER22/23EK with a favorable and the N363S and the Bcl1 with a more adverse profile. Importantly, the N363S and the Bcl1 are found to increase cortisol responses to a psychosocial stressor. As a result, the whole body will suffer from overexposure with possible adverse effects on metabolism, cardiovascular control, immune function, and behavior. Also in the MR gene, variants are being identified that are associated with dysregulated autonomic, behavioral, and neuroendocrine responses. The data suggest that these MR and GR variants contribute to individual differences in resilience and vulnerability to stressors, and that these receptors therefore are potential drug targets for recovery of homeostasis and health.
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MESH Headings
- Adaptation, Physiological
- Humans
- Hydrocortisone/metabolism
- Polymorphism, Single Nucleotide/genetics
- Receptors, Glucocorticoid/genetics
- Receptors, Glucocorticoid/metabolism
- Receptors, Mineralocorticoid/genetics
- Receptors, Mineralocorticoid/metabolism
- Stress, Physiological/genetics
- Stress, Physiological/metabolism
- Stress, Psychological/genetics
- Stress, Psychological/metabolism
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Affiliation(s)
- Roel DeRijk
- Department of Psychiatry, Leiden University Medical Center, 2300 RC, Leiden, The Netherlands
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24
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Bledsoe RK, Madauss KP, Holt JA, Apolito CJ, Lambert MH, Pearce KH, Stanley TB, Stewart EL, Trump RP, Willson TM, Williams SP. A Ligand-mediated Hydrogen Bond Network Required for the Activation of the Mineralocorticoid Receptor. J Biol Chem 2005; 280:31283-93. [PMID: 15967794 DOI: 10.1074/jbc.m504098200] [Citation(s) in RCA: 164] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Ligand binding is the first step in hormone regulation of mineralocorticoid receptor (MR) activity. Here, we report multiple crystal structures of MR (NR3C2) bound to both agonist and antagonists. These structures combined with mutagenesis studies reveal that maximal receptor activation involves an intricate ligand-mediated hydrogen bond network with Asn770 which serves dual roles: stabilization of the loop preceding the C-terminal activation function-2 helix and direct contact with the hormone ligand. In addition, most activating ligands hydrogen bond to Thr945 on helix 10. Structural characterization of the naturally occurring S810L mutant explains how stabilization of a helix 3/helix 5 interaction can circumvent the requirement for this hydrogen bond network. Taken together, these results explain the potency of MR activation by aldosterone, the weak activation induced by progesterone and the antihypertensive agent spironolactone, and the binding selectivity of cortisol over cortisone.
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Affiliation(s)
- Randy K Bledsoe
- Department of Gene Expression and Protein Biochemistry, GlaxoSmithKline, Research Triangle Park, North Carolina 27709, USA.
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25
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Meneton P, Jeunemaitre X, de Wardener HE, MacGregor GA. Links between dietary salt intake, renal salt handling, blood pressure, and cardiovascular diseases. Physiol Rev 2005; 85:679-715. [PMID: 15788708 DOI: 10.1152/physrev.00056.2003] [Citation(s) in RCA: 447] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Epidemiological, migration, intervention, and genetic studies in humans and animals provide very strong evidence of a causal link between high salt intake and high blood pressure. The mechanisms by which dietary salt increases arterial pressure are not fully understood, but they seem related to the inability of the kidneys to excrete large amounts of salt. From an evolutionary viewpoint, the human species is adapted to ingest and excrete <1 g of salt per day, at least 10 times less than the average values currently observed in industrialized and urbanized countries. Independent of the rise in blood pressure, dietary salt also increases cardiac left ventricular mass, arterial thickness and stiffness, the incidence of strokes, and the severity of cardiac failure. Thus chronic exposure to a high-salt diet appears to be a major factor involved in the frequent occurrence of hypertension and cardiovascular diseases in human populations.
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Affiliation(s)
- Pierre Meneton
- Institut National de la Santé et de la Recherche Médicale U367, Département de Santé Publique et d'Informatique Médicale, Faculté de Médecine Broussais Hôtel Dieu, Paris, France.
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